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Article Summaries for Patients

The following article summaries are available for patients:

 

What is the Role of Dependence-Related Behavior in Medication Overuse Headache?
Françoise Radat MD, PhD; Michel Lanteri-Minet MD, PhD
November/December 2010 (Volume 50, Issue 10, Pages 1597-1611)

Patient Summary, Autumn Klein, MD, PhD
Medication overuse headache (MOH) is a chronic headache in which medications are taken regularly and contribute to worsening and perpetuating headache. Almost any medication taken acutely to treat headache can lead to MOH, but some more than others, including barbiturates (a compound found in Fioricet and Fiorinal) and opiates (like morphine or Oxycodone). This article discusses the biological, psychological, and genetic relationships with MOH. In some people with MOH, it has been shown that there is a physical and psychological dependence on the medication, leading to behaviors of seeking medication and requiring more medication for an effect. These dependent behaviors also show a strong genetic component. In treating MOH, if dependent behaviors are present, then education, treatments such as antidepressants, and relaxation should be used for the best outcomes. Despite this, there are still many people who relapse.

Comments:
Dependent behaviors in MOH suggest that certain medications such as barbiturates and opiates should be avoided. While not everyone given these medications will become dependent on them, patients and physicians should be aware of this potential and actively monitor the amount and frequency of acute medications in the treatment of headache. 

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Ictal epileptic headache mimicking status migrainosus; EEG and DWI-MRI findings
Vincenzo Belcastro MD, Pasquale Striano MD, PhD, Laura Pierguidi MD, Paolo Calabresi MD, PhD, Nicola Tambasco MD, PhD
Early View ahead of print

Patient Summary, Autumn Klein, MD, PhD
Migraine and epilepsy are similar brain processes with very different endpoints – headache or seizure. However, not all seizures are convulsions. They can have symptoms of transient speech difficulties, small shaking movements, or visual changes. Mild seizures may even resemble migraines. In this case, a 20 year old woman who had a brain injury at the age of 8 presented with three days of nausea, light sensitivity, vomiting, and headache - similar to prior migraines but longer and unresponsive to medications. Brain imaging and electroencephalogram (EEG), or a brain wave test, showed that she had an old scar on her brain and that she was having seizures from the region of the injury. Seizure medication quickly resolved her symptoms.

Comment: Migraines are common (about 20% of the population has migraine) and seizures are not (about 0.5-1% of people), but in migraineurs, there is a higher rate of seizures (twice that in the general population, or ~1-2%). In cases where headaches are unresponsive to medications, or there are neurological symptoms with the headache (i.e. aura such as visual changes, numbness, tingingling, weakness, etc.) then considering seizures and getting an EEG is reasonable. It can be difficult to differentiate seizures and migraines, so if there is any concern, discuss it with a physician or neurologist. 

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 Increased Prevalence of Sleep Disorders in Chronic Headache: A Case Control Study
Elisa Sancisi MD, PhD, Sabina Cevoli MD, PhD, Luca Vignatelli MD, PhD, Marianna Nicodemo MD, Giulia Pierangeli MD, PhD, Stefano Zanigni MD, Daniela Grimaldi MD, PhD, Pietro Cortelli MD, PhD, Pasquale Montagna MD
October 2010 (Volume 50, Issue 9, Pages 1464-1472)

 

Patient Summary, Autumn Klein, MD, PhD
It is hypothesized that sleep disturbances may lead to more frequent headaches (HA). The aim of this study was to determine the occurrence of sleep disorders in patients with chronic headache (>15 days/ month) as compared to patients with episodic HA (<8 days/month). Patients kept a HA diary for three months and then were interviewed about sleep habits (falling asleep, arousals at night, waking early, snoring, daytime sleepiness) and given structured evaluations about mood and anxiety. These researchers found that patients with chronic HA had significantly more insomnia and snoring as well as more anxiety and depression. Those with chronic HA also were using more medications for sleep and more antidepressants.

The participants in this study were referred to a HA center, and so were likely a group with more troublesome headaches. In addition, they self-reported sleep disturbances, which may lead to an over- or underestimate of problems. However, despite these biases, this study raises awareness of sleep and mood as topics that should be discussed openly between physicians and patients and be addressed as symptoms to treat in order to help chronic HA management. 

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 Adverse Childhood Experiences and Frequent Headaches in Adults
Robert Anda MD, MS, Gretchen Tietjen MD, Elliott Schulman MD, Vincent Felitti MD, Janet Croft PhD
October 2010 (Volume 50, Issue 9, Pages 1473-1481)

 

Patient Summary, Autumn Klein, MD, PhD
Childhood abuse may lead to an increased risk of disease in adults. In patients with migraine, it has been shown that there is a high rate of childhood abuse and neglect, but this association has not been studied in the general population with headache. Using the Adverse Childhood Experiences (ACE) Study, retrospective reports of childhood abuse were collected, and then patients were prospectively followed for several medical outcomes. The purpose of this study was to look at the relationship between ACEs and patients with frequent headaches. Adverse childhood experiences were considered to be abuse (emotional, sexual, or physical), and household dysfunction (exposure to mental illness, substance abuse, etc.) with scores ranging from 0-8, with 8 being the most abuse Headache patients were identified by answering the question ‘Are you troubled by frequent headache?’ The average age of responders was 56 and 39% were college graduates. The risk of headache increased as the ACE score. Those with ACE scores > 5 had twice the risk of headache as those with an ACE score of zero.

Comment:  Stressful childhood experiences may be associated with increased disease later in life. It is not clear how this happens, but stress hormones may alter normal body functions and predispose people to more disease. While this study asks about events in the past, which may lead to difficulty with recalling past details, the results are still striking - the more abuse and exposure to a dysfunctional environment during childhood leads to more headache. Recognizing these connections will help so that therapy or other medication can be incorporated as part of the treatment for headache.

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 Predictability of Future Attacks by Migraineurs – A Prospective Observational Study
X. Henry Hu MD, PhD, Wendy Golden MD, MPH, Susan C. Bolge PhD, Bozena Katic MPH, MA, Ya-Ting Chen PhD, MPH, Samuel Wagner PhD, Roger Cady MD
September 2010 (Volume 50, Issue 8, Pages 1296-1305)

 

Patient Summary, Autumn Klein, MD, PhD
Being able to predict when a migraine may occur could be valuable information for headache sufferers to help decrease the severity and disability of an attack. This study used an internet-based questionnaire to ask subjects to predict their next headache including day, time of day, and location. The results were surprising. Participants were not very good at predicting their next headache. Only 9% could predict time, day, and location of the next headache, and 16% could predict none of these. The good news is that about 70% of participants could predict the location where the next headache would occur and 21% could predict within three days when the next headache would happen.

Only about 60% of those asked to participate in this study responded, but the information gathered indicates that headache patients cannot predict when their migraines will occur. Since taking medication at the onset of headache improves treatment outcomes, having medication readily available at all times is the best way to treat headaches early and effectively.

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The Prevalence of Neck Pain in Migraine
Anne H. Calhoun MD, Sutapa Ford PhD, Cori Millen DO, Alan G. Finkel MD, Young Truong PhD, Yonghong Nie MS
September 2010 (Volume 50, Issue 8, Pages 1273-1277)

Patient Summary, Autumn Klein, MD, PhD
In this study, the authors compared how often patients got nausea or neck pain with their migraines. Patients at headache clinics and in the general community were included and patients with fibromyalgia and cervicogenic headache (neck pain with limitation of movement of the neck) were excluded. Almost all of these patients were women and half of them had chronic daily headache (headache for >15 days of the month). They found that neck pain was more common at any intensity of headache and that the number of patients reporting neck pain increased with increasing frequency of headaches.

Comment:
Neck pain is often not recognized as a significant symptom associated with migraine. This article shows that neck pain is more common than nausea in migraine patients. It also emphasizes that this symptom is not mentioned by patients, and doctors do not often ask about it. Neck pain may serve as a signal (warning) for impending migraine and may be a better standard by which to gauge severity of migraine and measure treatment.

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Migraine and Obesity: Epidemiology, Mechanisms, and Implications
B. Lee Peterlin, DO; Alan M. Rapoport, MD; Tobias Kurth, MD, ScD
April 2010 (Volume 50, Issue 4, Pages 631-648)

Patient Summary, Autumn Klein, MD, PhD
Obesity affects almost one third of American, reduces quality of life, and increases morbidity and mortality. Obesity also increases pain from increased weight and structural changes, but it is unclear how obesity can increase other painful processes such as migraine. This article reviews the literature on obesity and migraine. Many studies use body mass index (BMI; a function of height and weight or kg/m2) as a surrogate for obesity and a measure of body fat. Body mass index < 18.5 is underweight, 18.5-24.9 is normal, 25-29.9 is overweight and >30 is obese. The distribution of body fat into total body obesity (TBO) and abdominal obesity (Ab-O) can also predict future disease. Men have more Ab-O, but Ab-O also increases in postmenopausal women. Chronic daily headache (CDH; headache for >15 days of the month) is increased in TBO and the transition from episodic headache to CDH is increased in TBO. Migraine is also increased in those who are underweight and TBO. Interestingly, older men and women (those >54 years old) had no association with migraine and TBO. In young people, it seems that migraine is increased in those with Ab-O, but this is not the case in older men and women. This article also discusses hormonal influences of headache, appetite, and obesity. While the precise mechanisms are not fully known, these substances, serotonin, orexin, adiponectin, and leptin, have been shown to modulate pain and inflammation, two main features of headaches and migraines.

Obesity is difficult to measure directly, so indirect measures like BMI are used in these studies. In addition, many of these studies relied on participants their measurements and headaches so height is likely over-reported and weight under-reported, resulting in an inaccurate BMI. However, for many reasons in addition to reducing headache and migraine, it is still important to maintain a moderate weight.

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Child Maltreatment and Migraine (Parts I, II, and III)
Gretchen E. Tietjen, MD; Jan L. Brandes, MD; B. Lee Peterlin, DO; Arnolda Eloff, MB,CHB,MME; Rima M. Dafer, MD, MPH; Michael R. Stein, MD; Ellen Drexler, MD; Vincent T. Martin, MD; Susan Hutchinson, MD; Sheena K. Aurora, MD; Ana Recober, MD; Nabeel A. Herial, MD, MPH; Christine Utley, MSN, CNP; Leah White, MPH; Sadik A. Khuder, MPH, PhD
January 2010 (Volume 50, Issue 1, Pages 20-51)

Patient Summary, Autumn Klein, MD, PhD
In these articles, Dr Tietjen draws the associations between migraine headaches and physical and emotional abuse and neglect in childhood and adulthood. From eleven headache centers, 1348 patients (88% were women, average age 41) responded and almost 60% reported some form of abuse or neglect in childhood; the most common was emotional abuse. Of those who experienced childhood abuse, 43% were re-victimized in adulthood. Depression was noted in 28% and anxiety in 56% with higher rates in those experiencing childhood trauma. Physical and emotional abuse and neglect were significantly associated with chronic migraine (>15 days/month) and transformation of migraine from episodic (<15d/month) to chronic migraine. Additionally, those with a history of abuse had earlier onset of migraine.

Childhood abuse is known to be associated with increased rates of depression, anxiety, and headache, but this is the first study that has documented this in a migraine population. While these findings are not surprising, the rates of abuse and neglect are much higher than expected. For those with a history of childhood abuse, these articles highlight the need for a therapist or psychiatrist to be involved in the migraine treatment team to provide optimal care.

Click below to read the articles:

Part I: Prevalence and Adult Revictimization: A Multicenter Headache Clinic Survey
Part II: Emotional Abuse as a Risk Factor for Headache Chronification
Part III: Association With Comorbid Pain Conditions

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